Free 36249.pdf - Indiana

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Public Employees' Retirement Fund
143 West Market Street, Suite 800 Indianapolis, IN 46204-2899 Telephone: (317) 233-4162 Toll-free: (888) 526-1687 Fax: (317) 234-5922 (Local) (866) 591-9441 (Toll-free) E-mail: [email protected] Web site: www.in.gov/perf

Transfer of Service Credit
State Form 36249 (R4 / 12-08) Approved by the State Board of Accounts, 2009

Indiana State Teachers' Retirement Fund
150 West Market Street, Suite 300 Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 Toll-free: (888) 286-3544 Fax: (317) 232-3882 E-mail: [email protected] Web site: www.in.gov/trf

(Check one)

TO: RE:

Public Employees' Retirement Fund Transfer of Retirement Service Credit

Indiana State Teachers' Retirement Fund

Request (check one)

This form is used for the purpose of transferring service credit and the associated funds between the Public Employees' Retirement Fund (PERF) and the Indiana State Teachers' Retirement Fund (TRF).
REQUESTING ORGANIZATION COMPLETES
Member's name (First, Middle, Last) Other name/maiden name
(if applicable)

Inquiry Transfer Service Credit/Funds

Last 4 digits of the Social Security number Member's account number (if applicable) Requested by Date of birth
(mm/dd/yyyy)

Street address

Anticipated retirement date
(mm/dd/yyyy)

City

State

ZIP Code

Date
(mm/dd/yyyy)

RECEIVING ORGANIZATION COMPLETES

The member named on this form has entered employment covered by this Fund. List the creditable service which this member may retain with your Fund. If the member terminated employment and was re-employed in a Fund-covered position, list the different periods of covered employment. Employer number Start date
(mm/dd/yyyy)

End date
(mm/dd/yyyy)

Service credit Years Months

Total service credit
RECEIVING ORGANIZATION COMPLETES
Member Contributions Employer Contributions Interest Total Total as of
(mm/dd/yyyy)

0

0

December 31,1986 After-Tax Contribution

Inquiry completion date (mm/dd/yyyy)

$
Processed by

$
Date (mm/dd/yyyy)

$
Manager approval

$
Date (mm/dd/yyyy)

$
Transferred by Date (mm/dd/yyyy)